DEXTER FAMILY PRACTICE

REDDY HEALTH CENTER

ANNUAL AFFORDABLE PRIMARY CARE HEALTH MAINTENANCE COVERAGE CONTRACT

Thank you for choosing Dexter Family Practice for your primary care. It is our pleasure to provide you with quality affordable health maintenance coverage.

This agreement is in effect beginning on ____________________ and expires on ___________________. Below is the list of health plans offered. Please choose the plan that best suits your healthcare needs. This plan is payable in advance and each year at renewal time.

                   PLAN                                                PRICE

                   Basic                                                 $175.00

                   Silver                                                 $340.00

                   Gold                                                  $490.00

                   Platinum                                             $1035.00

I have chosen the ______________plan in the annual amount of $__________. I have enclosed this amount by check/cash/money order/credit card. I agree that this is a non-refundable contract and is my responsibility to renew annually.

_________________________________                  _________________________

Patient Signature                                                             Date

_________________________________                  __________________________

Witness                                                                           Date